Dr Christine O'Malley
“It always rains on my birthday,” I said, aged 10. A kindly adult answered, “it only seems that way”.
To me it was a truth, an observation. I decided to make a mental note of the weather on my birthday each year. After 10 years of rain on 1 May, I felt the case was proven.
I take a long view and I respect evidence.
When the CervicalCheck story burst into our lives, my thoughts went back 10 years. That was a strange time.
US firms lined-up to replace public services but the details were secret, because it was “commercially-sensitive information”. The new consultant contract was clearly based around co-located private hospitals, but doctors’ concerns were dismissed as “vested interests”. Health watchdog HIQA was set up and had no oversight role in the commercial sector.
Ten years ago, the Mid-West was a pilot for outsourcing cervical smears to the US. My GP friends said that, compared to the Irish hospital labs, there were too many low-grade abnormalities reported. Lots of anxious women had to be referred to hospital clinics, but were in fact healthy.
We know now that the head of quality assurance for cytology also had concerns. He had evidence that high-grade abnormalities were not being picked up in the US; cancers would be missed.
This is not my area of expertise, but like everyone else, I’ve had the radio on constantly and I’ve bought stacks of newspapers.
I’ve also looked at any data I can find, including Programme reports from the early years. Quality assurance is mentioned constantly. However, CervicalCheck seemed to regard lab accreditation as a guarantee of quality.
I don’t think a doctor would get away with that in a court case, or in front of the Medical Council. We’re expected to look at evidence. Health administrators can’t, so they use external measures of quality.
I remember thinking that CervicalCheck was set up like a postal service, sending smears to the US and results to GPs. Issues such as quality and liability were outsourced with the contract. The US doctors reporting on Irish tests didn’t even have to be on the Irish Medical Register.
In those early reports, over-reporting of minor abnormalities is noted. I didn’t see efforts to address the more worrying issue — under-reporting of major abnormalities.
As the days went by, personal tragedies emerged one by one, each woman, each family.
The media pointed at doctors for not telling patients; the politicians said mandatory disclosure was the answer. I wondered about lab quality.
Very slowly, information is coming out.
In 2014, an audit was done of 1,480 women who developed cancer since the start of the Programme. When those smears were reviewed, 209 cases should have been reported differently. That’s 14 per cent.
Yes, the test is imperfect. And mistakes happen too. The issue is how frequent those mistakes are, and how bad, and whether there is variation among the labs.
Why wasn’t the audit done before 2014? It should be routine in a national screening programme. Maybe that’s “commercially sensitive information”.
We heard about the US labs: Legal case, gagging orders, legal letters preventing disclosure.
One US company sent Irish smear tests to a sister lab in the UK. The lab is accredited and it’s all within the terms of the HSE contract, but the effect is a fragmented system. Questions are being asked about the oversight by doctors, and whether Irish smears have been sent to labs anywhere else.
Then there’s the debate about cost.
When Vicky Phelan told us her shocking story, she pointed the finger of blame at then Minister Mary Harney for outsourcing cervical smears to the US.
I remember Mary Harney saying we had to, because the US lab was one-third the price of the Irish labs. Most people thought, ‘rip-off Ireland again.’
To me, it simply didn’t make sense. How could an American lab be so cheap?
That was the time when Mary Harney said cancer units in public hospitals around the country had to close because patients deserved a centre of excellence.
Cost versus quality: Are the rules different for commercial contracts?
On Morning Ireland, a senior lab scientist said one lab appears to be finding fewer high-grade abnormalities. We know it’s not the Coombe.
If the labs differ in quality, surely Irish women deserve to have their tests read in a laboratory centre of excellence.
I really enjoyed the IMO AGM this year. It’s funny, because I went with very low expectations. Since leaving work, I feel rather irrelevant. And yet my views are as fiercely held as ever.
But the AGM was back to ‘our’ hotel, Hotel Europe in Killarney. The location is stunning. Simply looking across the lake at mountains is good for the soul. Add in great food and lovely staff and it’s the place to be. It would be a shame to miss it.
Annie (stage manager) booked in immediately – it’s her favourite hotel.
On the way down, I heard the soothing, measured tones of Peadar Gilligan (incoming President) on the news. It’s an IMO tradition.
Shortly after we arrived, I got a message from The Irish Times. They’re printing my article the next day! It’s a light-hearted look at trolleys. (Yes, seriously.)
I feel better. Then I start to worry. What will the emergency medicine crowd think of my article? I nab Peadar – he likes it. Whew!
I have another prop with me: The answer to a parliamentary question, which confirms that the HSE have no data (their emphasis) on trolley patients, as regards age or illness. It’s because HIPE coding is not done unless the patient physically moves to a ward. How can the HSE solve the trolley problem if they know nothing about the patients?
Peadar suggests I use it during the afternoon motions session.
By now, quite a crowd has gathered, including a healthy turn-out of articulate NCHDs. It’s great to catch up with old friends, mostly people I meet only at the AGM. Later, the hall is packed for the panel discussion on Sláintecare.
The weather was not welcoming in Killarney at first. The mountains were greyed out by the rain. Storm winds herded chairs and tables along the terrace as Matt (psychiatrist, musician and MC extraordinaire) gave a talk on depression. Was nature in sympathy?
But the IMO always brings the sunshine.
I skipped the talk on GDPR and sat outside, watching the sun chase the last clouds from the mountain. Strangely beautiful music came from a balcony overhead. I looked up and saw Larry (GP and piano player) also listening. Roisin Dubh he called down to me. So we sang a few lines “A Roisin, na biodh bron ort…” as Ina (Chair of the Public Health Doctors) played the uileann pipes. Future committee meetings may be very interesting.
Maybe because of the setting, I fell into a number of remarkable and highly personal conversations with people I don’t know very well. It reminded me that we can never guess what troubles are going on in the homes and lives of colleagues.
Appropriately, there was a session on burn-out among doctors. The rates are astonishingly high. That was highlighted at the consultant national meeting, when two doctors referred, almost casually, to their experience of severe burn-out and how poorly their employers dealt with it.
As I attended debate sessions and listened to the life of a coroner, Annie was having her own AGM. There were long conversations with Niamh (artistic director) about funding for the arts in Wales and Ireland and discussions on plays with Aoife (theatre director) as well as getting advice from Matt (superhero) on handling an audience.
Meanwhile, Stephen Donnelly (FF health spokesperson) talked with Asam (surgeon and health realist) and me about medical employment and the peculiarity of labelling graduates in a negative manner as ‘non-consultant’. It’s interesting to get such a different perspective.
Later I met Minister for Health Simon Harris. He has a remarkable memory. We took up the conversation where we left off last year – beds and trolleys, of course. He wants to open beds quickly and can’t understand why so many were closed. I said if it’s very clear that beds are coming, morale might start to improve.
We live in hope, and there’s been very little recently.
There were late nights and some drink too. As I queued at the bar behind Frank Murray (RCPI Alcohol Bill advocate) I comforted myself that Joe (IMO Alcohol Bill advocate) told us women over-55 are not the problem as regards alcohol in Ireland. Great!
Very late on the last night, when even the IMO staff were off-duty, I sat with the media pack in the bar. Priscilla (Mindo) decided it was time to set me up on Twitter. The Irish Times and RTÉ were shaking wise heads, saying “Twitter at 3am – this won’t end well.” But it’s ok, I intend to lurk for a while. So we ordered another round and continued.
Annie and I had a weekend of fun and good company and a varied programme. Thanks to team IMO for a great AGM. And a big thank you to the kids who campaigned relentlessly to bring us all back to Hotel Europe.
During the Great Snow, I went through the snippets and articles of medical interest sitting on my kitchen table. Some are from the Medical Independent; others from newspapers. The best get stuck under fridge magnets, along with my favourite Mindo cartoons.
Let’s start with a lawyer who said the relationship between doctor and patient is “not merely a legal relationship, but one based on trust” and that a system of medical regulation that undermines trust “has got to be wrong”. Yes, yes, yes. It’s lovely to have new voices speaking up for what we do.
It ties-in nicely with a book review on unconventional treatments, which reminds the GP writer: “Never underestimate the power of the doctor themselves as the therapeutic agent.” I think modern hospitals ignore this part of patient care, as if it doesn’t matter.
The thing is, it’s not just GPs who are therapeutic agents. I didn’t know studies have shown “the biggest single factor that influences how happy a patient is after a knee replacement is how nice the doctor is to the patient”. Of all hospital specialties, orthopaedic surgery looks purely technical. Clearly, it’s not.
I find I learn a lot about our health system from individual patient experience, but consultant colleagues warn me: “That’s just anecdote, not evidence.” I’d have been at home at the meeting of medical story-telling in Galway. Yes, stories help “make sense of medicine’s complexities and uncertainties” and help maintain “a sense of humanity and what’s important”. Evidence-based practice has its place, but don’t leave people out.
An item that will live on my fridge door, for a while, is from the RCSI Millin Meeting. A UK Professor said specialism may be causing harm. It “breaks down continuity of care” and leads to endless referrals; professionals are reticent to make decisions outside their specialty, which leads to “paralysis in the system”.
I didn’t think I’d see that said in my professional lifetime, and by a surgeon. It’s the story of my life as a consultant, especially in recent years. A hospital admission used to be a one-stop shop to get everything sorted quickly for a patient. Now it’s just the prelude to months of clinics and scans and scopes.
The Professor also said that specialism leads to “medical tribalism” and specialists dominating guidelines. I hope that’s not what lies behind the loud campaign to “streamline” trauma services, which is covered in several newspaper cuttings.
Based on the horrors of reconfiguration in the Mid-West, here’s what will happen.
The new trauma centres will be overloaded with patients and trolleys; they’ll wonder what went wrong, how could the data lie? The HSE won’t believe them and will claim there are only two extra admissions per night. Referring hospitals will discover that patient transfers require complex decision-making and are very time-consuming. The ambulance service will fall further behind on their HIQA targets.
Please, please, do it in Dublin first. There’s some slight chance the problems will be noticed before it’s imposed on all of us.
If ‘reconfiguring’ in Dublin causes problems, maybe The Irish Times and Sunday Business Post might notice that the extreme trolley crisis in the Mid-West was caused by reconfiguration. It might dawn on them that “reconfiguring” services in Portlaoise will severely damage all nearby hospitals.
Meanwhile, an Irish Times editorial calls for trauma care on fewer sites, just like cancer services were “centralised in eight sites” a decade ago. But that’s not what really happened: as public services closed, private centres opened. The then Minister for Health Mary Harney even cut the ribbon on one such unit.
A Sunday Business Post article says the Government has refused to centralise services, “which would help reduce running costs”. I am not aware of any evidence that cost will be reduced.
If this comes as a surprise, look at the private hospitals — they have remarkably small staff numbers. They don’t talk about ‘economies of scale’, and for good reason. An acute hospital is not a manufacturing plant churning out pins, in the Adam Smith model, or complex items, such as cars. Acute care is more like crash repairs. It’s messy, with highly-individualised, bespoke solutions for each patient.
In economic terms, the true problem is that large hospitals have higher fixed costs than smaller units. That makes every case expensive, even the simple ones.
“I think sometimes we take an engineering analysis to the health system”, says Dr Mike Ryan from the World Health Organisation, when actually, health is “very organic”.
My final quote is from business guru Peter Drucker: “Large healthcare institutions may be the most complex organisations in human history” and “even small healthcare institutions are complex, barely-manageable places”.
I agree. That’s another one for my fridge.
Dr Christine O’Malley discovers hidden waiting lists in the NHS and concludes that there’s no place like home
Trolley crises and bed shortages bring about a sense of frustrating déjà vu for Dr Christine O’Malley
A family member’s struggle with anxiety brings into focus the problems of student life for Dr Christine O’Malley
Dr Christine O’Malley on cutting through the ‘HiPE’ and unspinning health service codswallop
Dr Christine O’Malley on her annual pilgrimage to the Dromineer Literary Festival and the connections it inspired
Dr Christine O’Malley ponders the big problems and calls for a reality check in our hospitals and Garda management
It’s remarkably hard to notice or recognise a sensory experience that you don’t share, writes Dr Christine O’Malley
Dr Christine O’Malley reflects on the crucial deficits in public hospital care following the recent unnerving experience of a family member
Public hospitals are designed to stop patients from meeting doctors, while women are often treated with less importance than men — but maybe that’s just Dublin, writes Dr Christine O’Malley